State Mental Health Policy: Washington State's Initiative to Disseminate and Implement High-Fidelity ACT Teams

The State of Washington embarked on its first comprehensive statewide implementation of high-fidelity Program of Assertive Community Treatment (WA-PACT) teams in 2006, primarily as a proactive response to decrease waiting lists for state hospital admissions and to provide community alternatives requested by stakeholders. Strong administrative leadership and legislative commitment resulted in full funding for ten teams as part of the state Mental Health Division's System Transformation Initiative. The state legislature, recognizing the need for an immediate solution to long waiting lists for hospital admissions, funded five additional state hospital wards with the understanding that the implementation of WA-PACT would allow for a gradual reduction in hospital capacity.

The WA-PACT initiative is aligned with the President's New Freedom Commission's recommendation to advance evidence-based practices ( 1 ). ACT has been implemented in 41 states and abroad and has been endorsed by federal reports and a multitude of peer-reviewed studies, including the 2001 Psychiatric Services' series dedicated to evidence-based psychiatry ( 2 ). Of the 41 states that have implemented ACT, only 20 report that they monitor fidelity ( 3 ) and only 15 report statewide ACT implementation ( 4 ). Despite ACT's strong evidence base and broad consensus for ACT implementation in every state ( 5 ), most state mental health authorities have not committed the resources necessary to widely implement high-fidelity teams ( 6 ). Washington State's focus is on statewide implementation of teams that achieve high fidelity to the ACT model. This is measured by an enhanced, state-funded fidelity tool that builds upon the Dartmouth Assertive Community Treatment Scale (DACTS) and is consistent with the trend of assessing the program fidelity of ACT teams to guide performance improvement efforts. This column identifies key strategies that can be used by other states seeking to implement high-fidelity ACT teams.

Background

The WA-PACT initiative takes place within the larger national context of comprehensive mental health system transformation. The System Transformation Initiative in Washington State examines overall systems change and emphasizes the use of evidence-based practices. Among the challenges facing the 2006 Washington State legislature were the declining availability of psychiatric beds in community hospitals and the need to reduce state hospital waiting lists. The legislature invested in five state hospital wards with the assumption that four of the five wards, a total of 120 beds, would close by October 2009 as a result of the successful discharge and community reintegration of WA-PACT consumers. Priority for WA-PACT admission is given to individuals appropriate for discharge from the state hospitals who have primary axis I and co-occurring substance use disorders.

A total of $10.4 million annually in state funds was appropriated to develop and operate ten new teams. In addition, each team received start-up funds equivalent to 33% of annual funding. The initiative was funded entirely with state revenue, with no Medicaid funding included. This afforded the state greater flexibility in the implementation and operation of the service. Each of the six full teams received $1.3 million annually, and each of the four half-teams received $650,000 annually. The WA-PACT Program Standards ( 7 ) define and describe full and half-teams in more detail. The seven western teams began enrolling consumers in July 2007, and the three eastern teams started three months later. Enrollment was deliberately incremental and followed the National ACT Standards' guidelines for admitting four to six consumers per month ( 4 ). When at full capacity, each full team will serve 80–100 consumers and each half-team will serve 42–50 consumers for a maximum of 800 consumers statewide. The teams, which are currently approaching full capacity, are providing services in 13 urban and rural counties of the 39 counties in Washington State.

Washington State, with 6.6 million people, is geographically diverse. The majority of the population resides in the western part of the state, primarily in the densely populated Puget Sound Region. The ten teams are strategically located to both emphasize population density and represent the state's diversity: seven teams operate in the western side of the state and three teams operate in the sparsely populated eastern side. The state operates two adult psychiatric hospitals. Western State Hospital, south of Tacoma, is the largest state hospital west of the Mississippi and has an average daily census of 875 patients. Eastern State Hospital, located near the Idaho border, has an average daily census of 304 patients.

The Washington State Mental Health Reform Act of 1989 decentralized the service delivery system by transferring state administration to regional support networks with catchment areas consisting of one or more counties. The state Mental Health Division contracts with regional support networks that have fiscal, administrative, and clinical authority for outpatient programs, including WA-PACT, in their catchment area. Licensed community mental health agencies are under contract with their respective regional support network to provide WA-PACT services.

On the basis of population size, the state selected nine regional support networks to administer the WA-PACT teams. In the fall of 2006 the state Mental Health Division reviewed WA-PACT implementation plans from each of the nine selected regional support networks. State Mental Health Division staff ensured adherence to the WA-PACT Program Standards and to contract deliverables and reviewed all implementation plans and budgets. Areas of concern were collaboratively addressed with each regional support network. Administrative costs were limited to ensure that the majority of funding was allocated for staffing of the teams.

By spring 2007 the state Mental Health Division and the Washington Institute for Mental Health Research and Training (WIMHRT) at the University of Washington provided comprehensive implementation feedback reports and conducted site visits with each regional support network to ensure consistency with legislative intent and the state Mental Health Division's expectations. A number of strategies have been found to facilitate the successful implementation of ACT, and the most crucial ones are highlighted in the following sections.

Crucial implementation strategies

Strong administrative support

State mental health authorities play a vital role in the implementation of evidence-based practices such as ACT ( 8 ). The clear vision from the state resulted in the legislature's providing funding comparable to that in other states with high-fidelity teams. The strong administrative and political will has served to catalyze and buttress WA-PACT's success during the critical start-up and first-year implementation phases. Funding was secured to hire two experienced community mental health clinical directors to lead implementation and ensure continued performance. The dedication of two full-time program administrators who had recent experience as providers established credibility among teams, regional support networks, and stakeholders.

Evidence-based training

The state Mental Health Division partnered with WIMHRT in WA-PACT's development and implementation. National ACT experts affiliated with WIMHRT provide ongoing consultation, training, and technical assistance to state Mental Health Division staff, regional support networks, and the ten WA-PACT teams. The first step in training the teams included a trip to Oklahoma to observe, shadow, and learn from high-fidelity urban and rural teams in Tulsa and outlying regions. The two state Mental Health Division program administrators, WIMHRT staff, selected regional support network staff, and two members from each team participated in the site visits. Direct observation of the Oklahoma teams in action was followed by on-site, individualized ACT start-up training with each team, which was provided by national and local ACT experts affiliated with WIMHRT staff.

Ongoing training and technical assistance has included monthly phone-based consultation with the team leader on clinical and program issues, as well as face-to-face visits to each program for direct observation of, and feedback on, team services and operations. Each team received one team-centered training booster session to enhance ACT-specific training and consultation and three day-long core-skills training sessions that featured state- and nationally recognized experts in areas such as motivational interviewing, integrated dual disorders treatment, and supported employment.

To foster a collaborative learning approach, team members participated in telephone-based group sessions targeted for their specific discipline. These sessions included group consultation and facilitated discussion of various team members' approaches to addressing cross-cutting issues. A comprehensive website ( www1.dshs.wa.gov/mentalhealth/sti_pact.shtml ) continually updates ACT resources and implementation progress.

Enhanced National ProgramStandards for WA-PACT teams

The establishment of robust program standards has been integral to WA-PACT's successful implementation. The WA-PACT Program Standards are an adaptation of the National Program Standards for ACT Teams ( 4 ) and serve as the basis for the model to which all WA-PACT teams adhere. National experts, including the coauthor of the National Program Standards for ACT Teams, Deborah Allness, were consulted during the initial phase of enhancing Washington State's standards. The state Mental Health Division facilitated multiple opportunities for feedback from the regional support networks during start-up and before the WA-PACT Program Standards' promulgation. To address concerns about coercion, enhancements were made to include more person-centered approaches. [A table listing the key enhancements made to the National Program Standards for ACT Teams is available as an online supplement at ps.psychiatryonline.org

The WA-PACT Program Standards provided the basis for developing a comprehensive set of policies and procedures guidelines. State Mental Health Division staff, in consultation with national ACT experts, integrated key areas from the WA-PACT Program Standards into guidelines and distributed them to the regional support networks and teams.

Updated ACT fidelity scale

The National Program Standards for ACT Teams inspired the development of an enhanced ACT fidelity tool to facilitate WA-PACT performance improvement. The state Mental Health Division provided initial funding for the development and pilot testing with each team during the first year of implementation of an enhanced fidelity scale based on the DACTS. The enhanced scale is the Tool for Measurement of Assertive Community Treatment (TMACT) (Monroe-DeVita MB, Teague GB, Moser LL, et al., unpublished, 2008). Enhancements to the DACTS include standards and measures for the development of team members' role expectations, enhanced team functioning, and integration of other evidence-based practices.

Fidelity review items tied to contract requirements

A significant number of the 44 TMACT fidelity review scale items have been referenced in, or incorporated into, the regional support networks' contractual requirements with ACT providers. The state Mental Health Division conducts contract monitoring with each regional support network to ensure that ACT services are being consistently implemented in accordance with those fidelity standards. For example, the WA-PACT Program Standards for team staffing composition are also fidelity scale items and are required by contract.

Linking fidelity review items with contract requirements has facilitated the successful statewide rollout of the teams. The linkage has been directly correlated with encouraging preliminary fidelity review findings. State Mental Health Division and WIMHRT staff interviewed 80 WA-PACT consumers during the baseline and six-month fidelity reviews. Over 90% of these consumers reported being highly satisfied with services, and no concerns were expressed about issues of coercion or loss of autonomy.

Challenges to implementation

Staff turnover

All ten teams conducted staff recruitment simultaneously, which caused regional competition among provider agencies during the initial recruitment phase. The systemwide rollout coupled with shortages of qualified professionals, particularly in rural areas, made recruitment challenging. Staff turnover continues to be the largest challenge. Most notably, half the teams have had team leader turnover, placing additional pressure on the newly developing teams to adapt to new leadership styles while continuing to enroll and serve consumers. Some teams continue to have difficulty retaining a full complement of qualified staff, which is exacerbated by shortages of licensed prescribers, registered nurses, and mental health and substance abuse treatment professionals. The state Mental Health Division has collaborated with regional support networks to grant temporary staffing waivers, allowing those teams to continue serving consumers while filling vacancies, without having to issue contract-based corrective action plans.

Affordable-housing shortage

The statewide paucity of safe and affordable housing remains a systemic challenge compounded by the multifaceted issues of renting to people with significant psychiatric disabilities. All teams continue to spend substantial amounts of their treatment capacity attempting to create viable housing alternatives. Teams have demonstrated a high level of commitment and creativity to secure low-income housing with varying levels of success. The majority of the teams report having to delay prospective consumers' discharge from state and community inpatient settings because of the housing shortage. The state Mental Health Division is currently working with other state-level agencies, homeless advocates, and federal and local housing funding entities to create housing options, particularly permanent supportive housing with an emphasis on housing for WA-PACT consumers.

Variability in agency culture

Organizational structure and culture differ significantly among teams. Consequently, some teams have been slower to assimilate ACT model practices and to meet established WA-PACT Program Standards. This variability in culture is attributed, in part, to the state's decentralized mental health service delivery system. Each regional support network manages its ACT providers' contracts with varying levels of adherence to the WA-PACT Program Standards. This factor, coupled with high staff turnover and existing agency practices and cultures, affects the ability of some teams to operate in alignment with the ACT model.

One challenging factor during the first year has been the tendency of some teams to operate in crisis mode rather than proactively providing clinical interventions. For example, some teams rely more heavily on conducting multiple daily medication monitoring services for most consumers, which leaves less time to develop targeted supported employment or substance abuse treatment services. To reinforce the WA-PACT Program Standards and to mitigate environmental influences, the state promotes changes in practice through ongoing consultation, training, and technical assistance provided by WIMHRT. This has helped to enhance the teams' understanding and incorporation of ACT and the other evidence-based practices within the model.

Next steps

The degree to which WA-PACT ultimately has an impact on the census in the two state hospitals, particularly the need for the temporarily added beds, will be closely monitored. Existing resources are being used to evaluate state hospital utilization and other outcomes related to WA-PACT services, including use of community hospitals, use of crisis services and emergency rooms, jail and prison recidivism, employment, substance use, and homelessness. Preliminary outcome data indicate low recidivism among enrolled consumers.

State funds are authorized to sustain all ten teams through the end of the biennium in June 2009. Ongoing funding will depend on the legislature and the success of the teams in achieving outcomes. Expansion of WA-PACT to other areas of the state may involve implementing specialized ACT teams to serve certain target populations, such as forensic and geriatric consumers; such expansion may be considered as future funding priorities allow. Sustainability will be supported through continued on-site fidelity reviews every six months plus the provision of ongoing training and technical assistance to enhance teams' performance. The completed baseline and six-month fidelity review findings are being analyzed and aggregated. Results will be included in a forthcoming article (Monroe-DeVita MB, Teague GB, Moser LL, et al., unpublished, 2008). The state Mental Health Division and WIMHRT are facilitating the large-scale piloting of Washington State's enhanced fidelity tool (TMACT) and dissemination of the program standards in other states. These findings will further guide empirically based improvements to the fidelity measurement tool and the ACT model in general.

The state Mental Health Division continues to evaluate and incorporate feedback solicited from the teams, regional support networks, and stakeholders. Ongoing collaborative efforts with other states and with national ACT experts will enable the state to assess how other high-fidelity teams achieve systemwide sustainability. The ultimate goal is to evolve WA-PACT as a fully integrated and ongoing high-fidelity component of the state's mental health service delivery system.

Implications for state mental health authorities

Securing adequate financing is vital for state mental health authorities to implement and sustain evidence-based practices ( 8 ). The mounting fiscal crisis that is being experienced by virtually all states presents immediate and potentially dire implications for states' efforts to sustain a high-fidelity ACT model. Goldman and colleagues ( 2 ) keenly noted, "It is a simple truism that a service system runs on its financing policies [and] if evidence-based practices are not covered services … they will not be used." Given the intensive nature of ACT and high start-up costs, strong leadership, a long-term vision, and the ability to demonstrate effectiveness are essential now, more than ever, to secure sustainable financing and ensure successful implementation.

State mental health authorities must collaborate with key stakeholders and persuasively communicate a long-term vision of how ACT fits within a person-centered framework, while also articulating the importance of fidelity and how it leads to improved consumer outcomes across a variety of life domains. The broader implications of ACT's success across other areas of interest and units of government should be evaluated and emphasized, including in the areas of the criminal justice system, homelessness, chemical dependency, and vocational rehabilitation. ACT contributes not only to the recovery of the individuals served and to reductions in use of inpatient services but also to the success of affiliated service systems, which also must demonstrate positive outcomes to continue to be viable.

Conclusions

A key advantage of Washington State's initiative has been the continued administrative and legislative support to ensure stable state funding and resources. As WA-PACT evolves, targeted training and technical assistance in conjunction with regular on-site fidelity reviews will continue to play key roles in developing high-fidelity teams. Budgetary constraints will pose potential challenges for states attempting to establish funding for sustainability and growth of statewide high-fidelity programs. However, to justify continued funding support for public mental health services, state mental health authorities should promote high-fidelity evidence-based practices such as ACT and highlight the positive performance and impacts of these programs on aligned and typically more costly systems of care.

Acknowledgments and disclosures

The authors thank Frank Jose, M.S.W., and David Hanig, M.S.W., for their helpful comments on earlier versions of this column.

The authors report no competing interests.